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Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care
Source: Adapted from Alfaro-LeFevre, 2012.
BOX 14-5 Actions that demonstrate clinical reasoning, judgement and decision-making skills
•
Applying standards and principles in the processes of
care, assessing systematically and comprehensively to
identify health-related problems
•
Evaluating information for bias, identifying
assumptions and inconsistencies, checking accuracy
and reliability
•
Determining the significance of data, distinguishing
relevant from irrelevant data, clustering relevant data
together, seeking missing information, drawing
reasonable conclusions
•
Identifying underlying causes and related factors,
considering multiple explanations and solutions
Judgement and decision making
•
Predicting complications, anticipating consequences
and including these in planning care
•
Determining priorities and including key stakeholders
in decisions, including patient and family perspectives
•
Managing risks, balancing risks and benefits of
interventions to the individual
•
Determining individualised outcomes and monitoring
progress
•
Communicating effectively, both orally and in writing
•
Identifying ethical issues and taking appropriate action
•
Identifying appropriate resources (human, information
and technological)
integrated and synthesised, the clinician must make a judge-
ment and decide what actions are to be taken and in what
order. Clinical judgement is interconnected with decision
making, which will be explained in the following section.
Decision making
Person-centredness also applies to reasoning and thinking,
as these ‘higher order thinking skills have no value unless
they are applied for the good of the patient’ (Tanner, 2006,
p. 209). Person-centred processes of care also require clini-
cians to be effective decision makers (Martin, 2002).
Indeed, the ultimate goal of clinical reasoning is the pro-
duction of effective decisions to direct the provision of care.
The complex and often confusing problems that arise from
the physical and psychosocial status of the person require
the nurse or midwife to collect, organise and process a large
amount of data. Martin (2002, p. 1) states that ‘the nurse
must recognise, interpret, and integrate new information and
make decisions about the course of action to follow. For
satisfactory client outcomes, complex decision making goes
hand in hand with critical thinking’.
The process of
decision making
in nursing, midwifery and
medical contexts is often described through a hypothetico-
deductive model (Banning, 2008). This type of decision
making comes from the science of logic. As described above,
once a problem has been identified, the first step involves the
collection of data (or cues), the interpretation of which leads
to the creation of a preliminary hypothesis to explain the data.
The data are then grouped into categories through a process
of pattern matching that has been established through previ-
ous experiences or learning. More data may then be collected,
providing the evidence to support or disprove the hypothesis,
which then determines the action to be taken. Duchscher (1999)
describes how this way of thinking underpins the traditional
concept of the nursing process.
This kind of scientific thinking is useful, as thinking
needs to be systematic. However, it can become a problem
for clinical reasoning if thinking is restricted solely to this
type of logical, scientific thought and does not also
acknowledge other ways of thinking—such as creative and
intuitive thinking as discussed above—as this restricts the
range of possible solutions that may be considered. Clinical
actions are discussed in the following section.
ACTIONS OF CLINICIANS
Like beliefs and values, decision making is often not overtly
expressed but is evident in the behaviour or actions of the
clinician. An
action
taken may be defined simply as ‘the
behaviour following on from a judgement or decision’
(Thompson & Dowding, 2002, p. 14). This action may be a
simple act or a series of acts; it may involve undertaking a
practical task or communicating with another clinician. Like
clinical reasoning, the actions taken by a clinician are
dependent on the confidence and competence of the clini-
cian and on an assessment of the risks involved (O’Neill,
Dluhy & Chin, 2005). Actions that demonstrate the use of
clinical reasoning, judgement and decision-making skills in
clinical practice are listed in Box 14-5.
Decisions to be made include when the action will be
undertaken. This is often referred to as ‘patient prioritisation’,
and is a skill that is enhanced by experience. When there are
time pressures, the quality of the decision and hence of the
action may be affected. This is a very important consideration
in contemporary healthcare, as time is seen as being inadequate
in most clinical settings (Duffield et al., 2007).
From what you have learnt so far, construct a
summary of each of the following steps required for
thoughtful practice:
1. Collect data (cues).
2. Recognise a problem.
3. Process the information using critical, creative and
intuitive thinking.
4. Come to a judgement.
5. Make a decision on what action to take (or not to take).
